A recent post over at Ezra Klein’s excellent Wonkblog caught my attention, both for being a post about a health economics issue, but also due to comments users had posted below. The post is about a recent set of projections about obesity and reports that there are new estimates that the burden of obesity in the US, if current trends continued, will be $550 billion over the next two decades. But this could be cut by almost 10% if trends continued 5% slower than they currently do. While this raises awareness of the importance of targeting healthcare interventions at preventing obesity and the diseases associated with obesity such as diabetes, it also raises important questions about responsibility for health. The comments section raises some important points:
It wouldn’t cost “us” a dime, if “we” weren’t forced to pay it.
How about fat people pay for their own problems?
This, perhaps uneloquent, point illustrates the quite common opinion that behaviour matters. Those individuals to whom a causal responsibility could be assigned for their condition, such as smokers, should have a smaller right to healthcare resources. The negative externality that arises from unhealthy food may be countered with a Pigouvian tax – fat people ‘paying for their own problems’. One country, Denmark, is already trying this by taxing butter. However, this tax is foolish – it is not butter consumption that leads to obesity! People are becoming ever more aware that it is refined carbohydrates that are more to blame. So, should a tax be placed on these products?
Obesity, and other diseases that may be viewed as being caused by personal behaviour, are more prevalent among the poor. A tax on the products consumed more by the poor (inferior goods) would be regressive and would contribute to inequality. You might argue that the (threat of) restriction to healthcare is enough to reduce consumption of these harmful goods, but, it is unlikely that that threat will make much difference, particularly since the negative effects occur in the future and time preference matters. This could lead you to the comment made by AnonymousBE1:
But, if obesity affects mortality, which it does on average, then there will be huge cost savings in terms of unpaid Social Security and other pensions. In addition, people who live longer do not have less expensive final years – it’s just that those final years come later. Obesity is a quality of life issue, but I am not convinced that it is a fiscal issue….
This is a salient point, and it is something which health economists know much about. But as liamdc710 points out (in not a strictly polite way):
Your analysis is as stupid as those who say smokers save people money because they die young from cancer. In fact, far fewer than half of smokers die from cancer at an age younger than the national life expectancy. For the majority of obese Americans, much like smokers, insurance companies, families, and the public health systems in place will see increasing expenditures on related diseases that require expensive life long treatment.
To which AnonymousBE1 replied:
Okay, well, there needs to be comparison studies of LIFETIME expenses, medical and pension and disability.
I think this final point is something on which most economists would agree. But, even if costs are greater for the obese, does this mean they have less of a right to quality of life?
Many commentators ascribe to a luck egalitarian point of view whereby health differences that are due to sheer luck should be ‘evened out’ after which personal responsibility should play a role – we should be responsible for the consequences of our actions. It is what John Roemer calls ‘the cost of freedom’. However, how individuals respond to the same diet or lifestyle is often a matter of sheer luck; an individual’s genetic lot plays a big role in their propensity for obesity or the damage they receive from alcohol, for example. Separating luck from behaviour is highly difficult, if not impossible. Furthermore, saying that an individual ought to behave in a certain way or else face the consequences does not necessarily mean that an individual can behave in that way.
Man, is this troubling. Looks like a Pigouvian moment to me.
Perhaps it is, but I think it comes down to what you view the function of the health system to be. Some view it as an insurance system. So those most likely to require healthcare should pay more which could be funded by such a Pigouvian tax. But, I believe a national healthcare system acts more as a system of redistribution. As I have mentioned in a previous post, health is a special good and a precondition for achieving any of the things we have reason to want in life. The socioeconomic differences in unhealthy behaviours are large. Working class men smoke more than the middle classes. But these differences in behaviour only account for some of the socioeconomic differences in health outcomes. We should see reducing inequalities as a greater social responsibility than punishing those who become ill partly as a result of their behaviour.